Americans’ use of supplements, prescriptions and over the counter (OTC) medications has been steadily increasing over the past couple of years. This increase can sometimes put patients at risk for complications and interactions. Believe it or not, a lot of over-the-counter medications can actually interact with your prescription medications (and affect how they work) without you even realizing it. Understanding how OTC medications, vitamins, supplements and prescriptions medications interact is important for your health and safety.
First off what is an OTC medication?
An over the counter medication, according to the Food and Drug Administration (FDA), is a medicine that you can buy without a prescription. These medications are considered safe and effective when you follow the directions on the label, or as directed by your health care professional.
The beauty of OTC medications is the convenience and ability, as a patient, to select a medication for your specific symptoms without a trip to the doctor. However, if you take any prescription medications, it is always recommended to check with your doctor or pharmacist before perusing the OTC aisles to ensure that it wont interact with any prescription medications.
What about vitamins, minerals, supplements?
Many people consider vitamins, minerals and supplements as “natural,” thinking that they won’t cause any problems or interactions. It may come as a surprise to some, but just like other OTC medications, vitamins, minerals and supplements can also interact with prescription medications.
It is important to understand the risks associated with the use of OTC medications, including those that give the illusion that they are natural or safe.
What are some common OTC and prescription drug interactions that I should know of?
- Blood Thinners like Coumadin (warfarin), Pradaxa, Eliquis, Xarelto and Plavix can interact with the following and cause an increased risk of bleeding:
- Vitamin E
- Ginkgo biloba
- Alka-Seltzer products
- Supplement drinks containing vitamin K (like Ensure or Boost)
- Nonsteroidal anti-inflammatories (NSAIDS) like ibuprofen (Motrin, Advil), (naproxen) Aleve, and aspirin.
- Birth control like Loesterin Fe, Ortho-Tri Cyclen, Seasonale and Yaz can become less effective in combination with St. John’s Wart. In fact, mixing these two products could lead to possible pregnancy
- SSRI Antidepressant Medications like Celexa, Lexapro and Prozac also interact with St. John’s Wort. Mixing these could increase your risk for serotonin syndrome, which can cause symptoms like diarrhea, seizures or even death.
- MAOI antidepressants like Parnate, Nardil and Marplan interact with the following and can also increase your risk for serotonin syndrome.
- Robitussin DM
- Mucinex DM
- Nyquil Cold & Flu
- Coricidin HBP Products
- Pain Medications like Norco, Vicodin, Percocet, Tylenol with Codeine and Ultracet don’t mix well with other products containing Tylenol, like Tylenol PM, Nyquil, Dayquil, and Mucinex. The maximum daily amount of Tylenol (acetaminophen) is now 3,000 mg per day, so mixing pain medications that contain acetaminophen with other Tylenol products can mean that you are taking more than the recommended amount of Tylenol without realizing it.
These are just a few of the common interactions between prescription and OTC medications! Remember, if you are concerned about any interactions between your medications, you can always check with your doctor or pharmacist.
It’s always exciting when a medication that once required a prescription becomes available over-the-counter. The ability to purchase a medication easily from the grocery story or pharmacy saves time and money!
Recently, the FDA approved Xyzal (levocetirizine) as an over-the-counter treatment for the relief of allergy symptoms. The approval of Xyzal Allergy 24hr adds another antihistamine option to the current OTC arsenal, but be sure to check with your doctor or pharmacist before adding any over-the-counter medications to your regimen.
So, what is the difference between the prescription and the OTC version of a drug like Xyzal?
You should know that before the status of these medications can be changed, the FDA requires that they are evaluated for both safety and efficacy, so the OTC version is just as safe and effective.
Having medications available without a prescription gives you the liberty to decide which medication you think will be right to help you and treat your specific symptoms, and may be more convenient and less expensive.
Typically, the medications that are available over-the-counter treat conditions that do not require extra monitoring or follow-up with a healthcare provider and thus can be used at your discretion. However, it is important to follow directions and ask your pharmacist or doctor if you have any questions or concerns.
What is OTC Xyzal indicated for?
Xyzal is used for the relief of symptoms associated with seasonal or year-round allergy symptoms, as well as the treatment of daily hives and itching. Xyzal allergy 24hr is an oral antihistamine with a 24 hour affect, and should only be taken once daily.
Xyzal Allergy 24hr will be available in the same strengths as the previous prescription-only products: 5 mg tablets and 0.5 mg/ml bottle of oral solution. Tablets are indicated for use in those 6 years and older while the oral solution is indicated for use in those 2 years and older.
There are too many allergy OTC medications. How do I choose?
As you may have noticed, there are quite a few OTC allergy medications on the market right now like Benadryl, Claritin, Zyrtec and Allegra. Although the convenience and availability of OCT medications is great, it may be overwhelming to some people. If you ever find yourself wandering the OTC aisles stunned by the amount of choices and products, remember that your pharmacist is always a great resource.
In order for the pharmacist to help select the best OTC medication for you, it’s important to always carry your current medication list. This list should include any samples from your doctor, specialty medications, vitamins, minerals, supplements, or other over-the-counter products that you use, even if its not on a regular basis.
For more information, and for help deciding which allergy medication is best for you, you can also check out this tool from our friends at Iodine.
Esophagitis is the term for irritation and injury to the mucosal lining of the esophagus. Medications are a common culprit and medication-induced esophagitis will give you pain behind the sternum (retrosternal pain) or heartburn 60% of the time. Other symptoms include pain with swallowing or the sensation of food getting stuck in your throat. Medications that irritate the esophagus usually cause the problem at the spot of esophageal narrowing.
These ten medications are well known to cause direct injury to the lining of the esophagus:
- Doxycycline is an old antibiotic used for numerous conditions including rosacea, acne and Lyme disease. Doxycycline causes a direct irritant effect on the esophagus often causing pain within hours of taking it. Of huge importance is to know that doxycycline hyclate causes more problems than doxycycline monohydrate—and both are cheap generics with similar effectiveness. Asking your doctor to substitute doxycycline monohydrate for doxycycline hyclate will result in much less irritation.
- Tetracycline is another antibiotic that’s a well-known cause of medication-induced esophagitis. It also causes a direct irritant effect on the esophagus. The way it can harm your esophagus is similar to a local acid burn; tetracycline has a pH less than 3 when dissolved in saliva or water.
- Clindamycin is a another antibiotic, often used for Staph skin infections or tooth infections. It is also associated with esophagitis due to it’s direct irritant effect.
- Aspirin. Taken daily by many for stroke and heart disease prevention, aspirin causes esophagitis by disrupting the protective barrier of the esophagus (the prostaglandin barrier). Lower doses of aspirin carry lower risks, but know this: the enteric coating (also known as “safety coating”) does not prevent the inhibition of prostaglandin and may not lower the risk of bleeding from aspirin. There are conflicting data about the benefit of the enteric coated formulations for preventing bleeding from the esophagus or stomach.
- NSAIDS (non-steroidal anti-inflammatory drugs), including ibuprofen (Motrin, Advil) and naproxen (Aleve). Similar to aspirin, these can lead to severe esophagitis, esophageal strictures, and bleeding. What can you do if you have symptoms of esophagitis while taking an NSAID? Use a protective agent like a proton pump inhibitors—omeprazole (Prilosec), pantoprazole (Protonix), esomeprazole (Nexium). You may also want to ask your doctor about using a COX-2 inhibitor like celecoxib (Celebrex) instead of your NSAID medication, which is safer on the esophagus and stomach.
- Alendronate (Fosamax) has caused more strictures of the esophagus than any other pill. Taken once a week, alendronate belongs to a class of medications known as bisphosphonates which are effective for the treatment of osteoporosis. You can lower your risk if you take it properly: with a full glass of water and don’t lie down for an hour.
- Ibandronate (Boniva) is similar to alendronate, but it is taken once a month. The risk is low but it is also a well known cause of esophagitis, esophageal ulcers and strictures.
- Risedronate (Actonel) is another osteoporosis medication. It has fewer gastrointestinal side effects compared with alendronate but it does carry some risk. Again, drink a full glass of water and don’t lie down for an hour after taking it.
- Potassium chloride supplements (KCl). Used as replacement in patients with low potassium (from diuretics or other causes) KCl is a well described cause of medication-induced esophagitis.
- Iron supplements/ferrous sulfate (FeSo4). Ferrous sulfate is found in most over-the-counter iron supplements. Similar to tetracycline, iron sulfate causes a local burn injury because it has a pH less than 3 when dissolved in saliva—it’s very acidic. Iron replacement options that are easier on the gut are Pur-Absorb iron packets, Feosol natural release (carbonyl iron), or those containing ferrous fumarate instead.
General tips to protect the gastrointestinal tract when taking these meds:
- Don’t take them and quickly lie down. You should stand or sit upright for at least 30 minutes, and should eat a meal afterwards.
- Make sure the amount of fluid ingested with the medication is enough. It is recommended you take your pills with 100 mL of water, which is about a half of a cup . . . not 25 ml as most folks do. In fact, ideally meds should be taken with at least 240 mL (8 oz) of water to minimize the risk of the tablet getting stuck in the esophagus and causing local damage.
The FDA recently ruled that Pylera will now require a boxed safety warning on its labeling. A boxed warning or “black box warning” is the most serious warning regarding potential side effects and is used to call attention to serious or life-threatening risks.
What is Pylera indicated for?
Pylera is used in combination with omeprazole to treat stomach and intestinal ulcers in patients with helicobacter pylori (h.pylori).
Why was Pylera given a boxed warning?
The boxed warning on Pylera is due to its potential for carcinogenicity, or the ability to cause cancer. During recent testing, Pylera has been shown to be cancer causing on mice and rats
If you are concerned about this boxed warning, be sure to talk to your doctor about other medications on the market for h.pylori. In fact, Prevpac and Omeclamox-Pak are both prescribed for h.pylori, and do not have a boxed warning.
What should I do if I experience an adverse effect to a medication?
An adverse effect to a medication should be reported to the FDA MedWatch program here. MedWatch is the FDAs safety information and adverse event reporting program. You can use MedWatch to report adverse events like serious side effects, product use errors, product quality problems, and therapeutic failures for human medical products, cosmetics, and prescription or OTC medications.
Call 1-800-332-1088 for more information on how to report an adverse effect.
Manufacturer Perrigo Pharmaceuticals has issued a voluntary recall for clindamycin/benzoyl peroxide gel (1.2%/5%), a topical medication used to treat acne.
This is a class II recall, the most common type of recall, which means that there is a situation where use of the recalled medication may cause temporary or medically reversible adverse health consequences, but the likelihood of serious adverse effects is small. For more information on the different types of recalls, see our overview here.
Who can recall a drug?
A manufacturer can voluntarily recall their medication, or the Food and Drug Administration (FDA) can request or require that a manufacturer recall a particular medication. In this case, the manufacturer has voluntarily recalled their clindamycin/benzoyl peroxide gel products, with the knowledge of the FDA.
Why was clindamycin/benzoyl peroxide gel recalled?
Perrigo Pharmaceuticals has voluntarily recalled their clindamycin/benzoyl peroxide (1.2%/5%) gel, due to the presence of a small amount of mold on the caps of the tubes. Clindamycin/benzoyl peroxide is the generic for the brand name drug Duac, which has not been affected by this recall.
The mold in the caps can present a risk for infection, especially in immunocompromised patients whose immune system can’t fight bacteria and mold.
Which products were recalled?
In this recall, the following lots of clindamycin/benzoyl peroxide (1.2%/5%) 45 gram tubes were affected:
#080806 (Exp 12/16), #080844 (Exp 12/16), #080963 (Exp 12/16), #080999 (Exp 12/16), #084109 (Exp 03/17), #084197 (Exp 03/17), #091090 (Exp 10/17), #092319 (Exp 11/17), #092399 (Exp 12/17), #092440 (Exp 12/17)
Have any other manufacturer’s been affected?
No. At this time only Perrigo Pharmaceuticals clindamycin/benzoyl peroxide gel has been recalled.
How can I find more information from the manufacturer?
The manufacturer, Perrigo Pharmaceuticals, can be reached by calling their toll-free recall phone number at 1-800-321-0105, or by visiting their website here.
Are patients who have taken this medication being notified?
No. This is a class II recall, which means that it isn’t necessary to notify you unless your doctor believes it may have a effect on your health. However, pharmacies with the affected lot in their inventory have been directed to stop distribution and arrange for product return.
If you have concerns that your prescription may be affected, contact your doctor for more information.